Background:There is no consensus treatment for knee dislocations with associated patellar dislocation. This systematic review provides an overview of current treatments and the authors preferred treatment algorithm. Knee dislocation with concomitant patellar dislocation is a rare occurrence and there is no standard of care for these injuries. This review seeks to provide a systematic review of literature and a proposed treatment algorithm for this injury pattern. Methods:A systematic review was performed following PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines using the PubMed, MEDLINE, and Cochrane databases in July 2024. Studies were assessed for human patients who sustained a knee dislocation with concomitant patellar dislocation. Results:The literature search yielded 288 titles and abstracts to be screened. Of the 288 articles, 281 titles and abstracts were excluded. Ultimately six full text articles were included. There were three case reports/series of acute knee dislocation with associated patellar dislocation and there were three case reports of chronic knee dislocation with associated patellar dislocation. In all studies, patellar instability was addressed surgically regardless of patient risk factors. Conclusion:Knee dislocation with associated patellar dislocation is a rare occurrence, but in general can be treated with the standard of care for a knee dislocation and then an assessment of risk factors for consideration of MPFL repair or reconstruction. Level of evidence:Level 4- systematic review of case reports and case series.

Background: The American Society of Anesthesiologists Physical status classification (ASA-PS) is a simple categorization of a patient's physiological status during the perioperative period. The role of ASA-PS in predicting operative risk and complications following tonsillectomy with or without adenoidectomy (T +/- A) has not been studied. The objective of the study was to identify the association of the pre-operative ASA-PS with 30-day complication rates and adverse events following T +/- A. Study design: A retrospective analysis was performed using data from the American College of Surgeons' National Surgical Quality Improvement Program database (ACS NSQIP) of patients aged 16 years or older who underwent T +/- A between 2005 and 2016. Patients were stratified into ASA-PS Classes I/II and III/IV. Patient demographics, preoperative comorbidities, pre-operative laboratory values, operation-specific variables, and postoperative outcomes in the 30-day period following surgery were compared between the two subsets of ASA-PS groups. Results: On multivariate analysis, patients with ASA class III and IV were more likely to experience an unplanned readmission (OR 1.39, 95 % CI 1.09-1.76; p = 0.007), overall complications (OR 1.49, 95 % CI 1.28-1.72; p < 0.001), major complications (OR 1.52, 95 % CI 1.31-1.77, p = 0.001), reoperation (OR 1.33, 95 % CI 1.04-1.69; p = 0.022), and extended length of stay > 1 day (OR 1.78, 95 % CI 1.41-2.25; p < 0.001) following a T +/- A. Conclusion: Higher ASA-PS classification is an independent predictor of complications following T +/- A. Surgeons should aim to optimize the systemic medical conditions of ASA-PS classes III and IV patients prior to T +/- A and implement post-operative management protocols specific to these patients to decrease morbidity, complications, and overall health care cost.

Abstract Background: Anterior lumbar interbody fusion (ALIF) has become an increasingly popular and effective treatment modality for various conditions of the lumbar spine. However, complications after this procedure can be costly. Surgical site infections (SSIs) are one of these types of complications. The present study identifies independent risk factors for SSI after single-level ALIF to identify high-risk patients better. Patients and Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify single-level ALIF patients from 2005 to 2016. Multilevel fusions and non-anterior approach procedures were excluded. Mann-Pearson χ2 tests analyzed categorical variables, whereas one-way analysis of variance (ANOVA) and independent t-tests analyzed differences in mean values of continuous variables. Risk factors for SSI were identified via a multivariable logistic regression model. A receiver operating characteristic (ROC) curve was generated utilizing the predicted probabilities. Results: A total of 10,017 patients met inclusion criteria; 80 (0.80%) had developed SSI and 9,937 (99.20%) had not. On multivariable logistic regression models, class 3 obesity (p = 0.014), dialysis (p = 0.025), long-term steroid use (p = 0.010), and wound classification 4 (dirty/infected) (p = 0.002) all independently increased the risk for SSI in single-level ALIF. The area under the receiver operating characteristic curve (AUROC; C-statistic) was 0.728 (p < 0.001), indicating relatively strong reliability of the final model. Conclusions: Several independent risk factors including obesity, dialysis, long-term steroid use, and dirty wound classification all increased risk for SSI after single-level ALIF. By identifying these high-risk patients, surgeons and patients can have more informed pre-operative discussions. In addition, identifying and optimizing these patients prior to operative intervention may help to minimize infection risk.

Background:ALIF (anterior lumbar interbody fusion) and other spinal fusion surgeries are among the most common orthopaedic procedures requiring blood transfusions. However, blood transfusions have been associated with various complications, including adverse reactions and infections. The present study aims to identify independent risk factors for blood transfusions in patients undergoing single-level ALIF specifically to better identify high risk patients and optimize perioperative management. Methods:All patients who had undergone single-level ALIF patients for the treatment of degenerative spinal conditions, excluding traumatic, pathologic, and infectious etiologies, were identified by querying a multi-institutional surgical registry from 2005 to 2018. Multi-level fusions, PLIF/TLIF, and posterior procedures were also excluded. Mann-Whitney-U-Tests were used to analyze continuous variables, while Fisher's-Exact-Tests/Bonferroni-Corrected-Tests were used for categorical variables. Multivariate logistic regression analysis with alternating backward stepwise elimination and forward entry was implemented to identify significant predictors for blood transfusions within 72 hours after incision. The predicted probabilities were used in post-regression diagnostics to generate a Receiver Operating Characteristic (ROC) curve to assess model performance. Results:4,792 single-level ALIF patients met inclusion criteria - 183 (3.82%) had received blood transfusions within 72 hours after incision and 4,609 (96.18%) had not. Age ≥60 years (OR 1.954, p<0.001), preoperative transfusions (OR 33.758, p=0.023), extended operative times (≥197.0 minutes; 75th percentile) (OR 4.645, p<0.001), ASA≥3 (OR 1.395, p<0.001) and preoperative hematocrit levels (Hct) 30.00-37.99 (OR 1.562, p=0.016) and Hct <30.00 (OR 6.334, p<0.001) were shown to be significant independent risk factors for perioperative blood transfusions. The area under the ROC curve (AUROC; C-statistic) was 0.759 (p<0.001), indicating relatively strong discriminatory ability/predictability of the final model. Conclusion:Several independent risk factors including age ≥60 years, preoperative blood transfusions and extended operative times increased risk for blood transfusion following single-level ALIF. The present study aims to help surgeons identify high-risk patients to better communicate postoperative expectations and optimize patients to reduce the risk of transfusions and secondary complications. Level of Evidence: III.

To determine the optimal level for the measurement of psoas cross-sectional area and examine the correlation with short-term functional outcomes of posterior lumbar surgery. Patients who underwent minimally invasive posterior lumbar surgery were included in this study. The cross-sectional area of psoas muscle was measured at each intervertebral level on T2-weighted axial images of preoperative MRI. Normalized total psoas area (NTPA) (mm2/m2) was calculated as total psoas area normalized to patient height. Intraclass Correlation Coefficient (ICC) was calculated for the analysis of inter-rater reliability. Patient reported outcome measures including Oswestry disability index (ODI), visual analog scale (VAS), short form health survey (SF-12) and patient-reported outcomes measurement information system were collected. A multivariate analysis was performed to elucidate independent predictors associated with failure to reach minimal clinically important difference (MCID) in each functional outcome at 6 months. The total of 212 patients were included in this study. ICC was highest at L3/4 [0.992 (95

OBJECTIVES:This study sought to delineate the postoperative outcomes in dialysis patients undergoing hip hemiarthroplasty (HHA) for the treatment of femoral neck fractures (FNF) in order to better optimise pre- and postoperative management and minimise short-term morbidity and mortality rates.METHODS:16,955 patients who had undergone HHA for femoral neck fractures from 2005 to 2018 were isolated from a multi-institutional surgical registry, of which 343 (2.0%) were on dialysis and 16,612 (98.0%) were not. The cohorts were identified/analysed for differences in their comorbidities, demographic factors, and 30-day postoperative complications using Fischer's exact tests and Mann-Whitney U-tests. Coarsened exact matching (CEM) was implemented in order to control for baseline difference in demographics and comorbidities. Multivariate logistic regression analyses were used to assess the impact of dialysis as an independent risk factor for various complications, including reoperations, readmissions, and mortality.RESULTS:Upon CEM-matching (L1-statistic <0.001), weighted multivariate logistic regression analyses demonstrated dialysis to be an independent risk factor for minor complications (OR 3.051, p < 0.001), pneumonia (OR 3.943, p < 0.001), urinary tract infections (UTIs) (OR 2.684, p < 0.001), major complications (OR 1.892, p < 0.001), unplanned intubation (OR 2.555, p = 0.047), cardiac arrest (OR 11.897, p < 0.001), deep vein thrombosis (DVT), (OR 2.610, p = 0.049), and mortality (OR 2.960, p < 0.001).CONCLUSIONS:Dialysis independently increased the risk for unplanned intubation, cardiac arrest, blood transfusions, pneumonia, DVT, and mortality. In communicating postoperative expectations, surgeons should aim to clarify the patients' preferences and potential resuscitation designations prior to surgical intervention due to the increased risk of serious complications. A lower threshold of suspicion for DVT in this population is reasonable. Identifying high-risk patient populations that may experience increased rates of complications, with the ensuing financial expenditures, due to medical complexity rather than subpar management may help providers avoid penalties in caring for these patients.

BACKGROUND CONTEXT: While cervical disc replacement (CDR) has been emerging as a reliable and efficacious treatment option for degenerative cervical spine pathology, not all patients undergoing CDR will achieve minimal clinically important difference (MCID) in patient-reported outcome measures (PROMs) postoperatively-risk factors for failure to achieve MCID in PROMs following CDR have not been established.PURPOSE: To identify risk factors for failure to achieve MCID in Neck Disability Index (NDI, Visual Analog Scale (VAS) neck and arm following primary 1-or 2-level CDRs in the early and late postoperative periods.STUDY DESIGN: Retrospective review of prospectively collected data. PATIENT SAMPLE: Patients who had undergone primary 1-or 2-level CDR for the treatment of degenerative cervical pathology at a single institution with a minimum follow-up of 6 weeks between 2017 and 2022.OUTCOME MEASURES: Patient-reported outcomes: Neck disability index (NDI), Visual analog scale (VAS) neck and arm, MCID.METHODS: Minimal clinically important difference achievement rates for NDI, VAS-Neck, and VAS-Arm within early (within 3 months) and late (6 months to 2 years) postoperative periods were assessed based on previously established thresholds. Multivariate logistic regressions were performed for each PROM and evaluation period, with failure to achieve MCID assigned as the outcome variable, to establish models to identify risk factors for failure to achieve MCID and predictors for achievement of MCID. Predictor variables included in the analyses featured demographics, comorbidities, diagnoses/symptoms, and perioperative characteristics.RESULTS: A total of 154 patients met the inclusion criteria. The majority of patients achieved MCID for NDI, VAS-Neck, and VAS-Arm for both early and late postoperative periods-79% achieved MCID for at least one of the PROMs in the early postoperative period, while 80% achieved MCID for at least one of the PROMs in the late postoperative period. Predominant neck pain was identified as a risk factor for failure to achieve MCID for NDI in the early (OR: 3.13 [1.10-8.87], p-value: .032) and late (OR: 5.01 [1.31-19.12], p-value: .018) postoperative periods, and VAS-Arm for the late postoperative period (OR: 36.63 [3.78-354.56], p-value: .002). Myelopathy was identified as a risk factor for failure to achieve MCID for VAS-Neck in the early postoperative period (OR: 3.40 [1.08-10.66], p-value: .036). Anxiety was identified as a risk factor for failure to achieve MCID for VAS-Neck in the late postoperative period (OR: 6.51 [1.91-22.18], p-value: .003). CDR at levels C5C7 was identified as a risk factor for failure to achieve MCID in NDI for the late postoperative period (OR: 9.74 [1.43-66.34], p-value: .020).CONCLUSIONS: Our study identified several risk factors for failure to achieve MCID in common PROMs following CDR including predominant neck pain, myelopathy, anxiety, and CDR at levels C5 -C7. These findings may help inform the approach to counseling patients on outcomes of CDR as the evidence suggests that those with the risk factors above may not improve as reliably after CDR. (c) 2023 Published by Elsevier Inc.

Background:The purpose of this study was to determine risk factors for blood transfusion in primary anatomic and reverse total shoulder arthroplasty (TSA) performed for osteoarthritis. Methods:Patients who underwent anatomic or reverse TSA for a diagnosis of primary osteoarthritis were identified in a national surgical database from 2005 to 2018 by utilizing both CPT and ICD-9/ICD-10 codes. Univariate analysis was performed on the two transfused versus non-transfused cohorts to compare for differences in comorbidities and demographics. Independent risk factors for perioperative blood transfusions were identified via multivariate regression models. Results:305 transfused and 18,124 nontransfused patients were identified. Female sex (p<0.001), age >85 years (p=0.001), insulin-dependent diabetes mellitus (p=0.001), dialysis dependence (p=0.001), acute renal failure (p=0.012), hematologic disorders (p=0.010), disseminated cancer (p<0.001), ASA ≥ 3 (p<0.001), and functional dependence (p=0.001) were shown to be independent risk factors for blood transfusions on multivariate logistic regression analysis. Conclusion:Several independent risk factors for blood transfusion following anatomic/reverse TSA for osteoarthritis were identified. Awareness of these risk factors can help surgeons and perioperative care teams to both identify and optimize high-risk patients to decrease both transfusion requirements and its associated complications in this patient population. Level of Evidence: III.

BACKGROUND CONTEXT:Although anterior cervical discectomy and fusion is believed to positively impact a patient's radicular symptoms as well as axial neck pain, the outcomes of cervical disc replacement (CDR) with regards to neck pain specifically have not been established. PURPOSE:Primary: to assess clinical improvement following CDR in patients with neck pain greater than arm pain. Secondary: to compare the clinical outcomes between patients undergoing CDR for predominant neck pain (pNP), predominant arm pain (pAP), and equal neck and arm pain (ENAP). STUDY DESIGN:Retrospective review of prospectively collected data. PATIENT SAMPLE:Patients who had undergone one- or two-level CDR for the treatment of degenerative cervical pathology and had a minimum of 6-month follow-up were included and stratified into three cohorts based on their predominant location of pain: pNP, pAP, and ENAP. OUTCOME MEASURES:Patient-reported outcomes: Neck Disability Index (NDI), Visual Analog Scale (VAS) neck and arm, Short Form 12-Item Physical Health Score (SF12-PHS), Short Form 12-Item Mental Health Score (SF12-MHS), minimal clinically important difference (MCID). METHODS:Changes in Patient-reported outcomes from preoperative values to early (<6 months) and late (≥6 months) postoperative timepoints were analyzed within each of the three groups. The percentage of patients achieving MCID was also evaluated. RESULTS:One hundred twenty-five patients (52 pNP, 30 pAP, 43 ENAP) were included. The pNP cohort demonstrated significant improvements in early and late NDI and VAS-Neck, early SF-12 MCS, and late SF-12 PCS. The pAP and ENAP cohorts demonstrated significant improvements in all PROMs, including NDI, VAS-Neck, VAS-Arm, SF-12 PCS, and SF-12 MCS, at both the early and late timepoints. No statistically significant differences were found in the MCID achievement rates for NDI, VAS-Neck, SF-12 PCS, and SF-12 MCS at the late timepoint amongst the three groups. CONCLUSIONS:CDR leads to comparable improvement in neck pain and disability in patients presenting with neck pain greater than arm pain and meeting specific clinical and radiographic criteria.

[This corrects the article DOI: 10.1016/j.artd.2019.10.006.].

There is a paucity of literature discussing appropriate anesthetic selection for interventional radiology procedures. The goal of this retrospective analysis is to assess the independent impact of anesthesia type on the short-term outcomes of endovascular lower extremity interventions for peripheral artery disease.

BACKGROUND CONTEXT Hounsfield units (HU), typically measured at L1-L2, have been identified as a surrogate marker for lumbar Bone Mineral Density (BMD). However, concern remains that L1-L2 BMD may not fully capture BMD differences throughout the lumbosacral spine and inadvertently provide inaccurate assessment. PURPOSE To evaluate the impact of age, gender and BMI on lumbar HU, compare the conventional L1-L2 HU measurements with the common levels of degenerative pathology, compare HU measurements among different vertebral levels and evaluate the distribution of HU within the individual vertebral bodies. STUDY DESIGN/SETTING Cross sectional study. PATIENT SAMPLE Consecutive patients presenting to a spine clinic between April2017 and January 2019 who underwent lumbar CT were selected. Previous lumbar surgery, tumor, fracture or infection were excluded. OUTCOME MEASURES HU measurements performed in 7 regions of each vertebral body: Mid-sagittal; Axial–Superior, Waist, Inferior; Axial at the waist–Anterior, Middle, Posterior. METHODS Association with age and BMI was evaluated using Pearson product-moment correlation. The difference between L1-L2 and L4 and L5 HU was assessed. Comparison of HU amongst levels and within each level was performed using ANOVA and paired t-tests. RESULTS A total of 100 patients (mean age=56years, BMI=26.4 kg/m2, 48% males) were included. Age showed a negative correlation with HU in all regions at all levels (p<0.0001). BMI and gender did not show an association with HU. Conventional L1-L2 HU overestimated L4 and L5 HU by at least 10 units in 32–67% of patients, depending on the region. S1 demonstrated higher HU than L3 (p=0.025) and L4 (p=0.029) in the mid-sagittal plane, and higher HU than all other levels in the Superior (p<0.0001) and Waist [overall (p<0.0001), and anterior (p<0.0001), middle (p<0.0001) and posterior (p<0.0001 to p=0.016)] regions in the axial plane, with no other between-level differences. From L1 to L4, HU in the Superior region was significantly lower than that in the Inferior region (p<0.0001 to p=0.003). The opposite was seen at S1, with a decrease in HU from Superior to Waist to Inferior (p<0.0001). At all levels, HU was lower in the Posterior region compared to the Anterior and Middle (p<0.001), with no difference between Anterior and Middle (p>0.05). CONCLUSIONS Although BMD at L1-L2 is often used as a marker of lumbosacral BMD, it may overestimate BMD of other levels. Furthermore, all levels demonstrated differences among various regions. These findings suggest the need for more detailed BMD estimation, especially in patients undergoing spinal instrumentation in whom variations in local BMD can be used to guide surgical planning and could potentially impact clinical outcomes. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. Hounsfield units (HU), typically measured at L1-L2, have been identified as a surrogate marker for lumbar Bone Mineral Density (BMD). However, concern remains that L1-L2 BMD may not fully capture BMD differences throughout the lumbosacral spine and inadvertently provide inaccurate assessment. To evaluate the impact of age, gender and BMI on lumbar HU, compare the conventional L1-L2 HU measurements with the common levels of degenerative pathology, compare HU measurements among different vertebral levels and evaluate the distribution of HU within the individual vertebral bodies. Cross sectional study. Consecutive patients presenting to a spine clinic between April2017 and January 2019 who underwent lumbar CT were selected. Previous lumbar surgery, tumor, fracture or infection were excluded. HU measurements performed in 7 regions of each vertebral body: Mid-sagittal; Axial–Superior, Waist, Inferior; Axial at the waist–Anterior, Middle, Posterior. Association with age and BMI was evaluated using Pearson product-moment correlation. The difference between L1-L2 and L4 and L5 HU was assessed. Comparison of HU amongst levels and within each level was performed using ANOVA and paired t-tests. A total of 100 patients (mean age=56years, BMI=26.4 kg/m2, 48% males) were included. Age showed a negative correlation with HU in all regions at all levels (p<0.0001). BMI and gender did not show an association with HU. Conventional L1-L2 HU overestimated L4 and L5 HU by at least 10 units in 32–67% of patients, depending on the region. S1 demonstrated higher HU than L3 (p=0.025) and L4 (p=0.029) in the mid-sagittal plane, and higher HU than all other levels in the Superior (p<0.0001) and Waist [overall (p<0.0001), and anterior (p<0.0001), middle (p<0.0001) and posterior (p<0.0001 to p=0.016)] regions in the axial plane, with no other between-level differences. From L1 to L4, HU in the Superior region was significantly lower than that in the Inferior region (p<0.0001 to p=0.003). The opposite was seen at S1, with a decrease in HU from Superior to Waist to Inferior (p<0.0001). At all levels, HU was lower in the Posterior region compared to the Anterior and Middle (p<0.001), with no difference between Anterior and Middle (p>0.05). Although BMD at L1-L2 is often used as a marker of lumbosacral BMD, it may overestimate BMD of other levels. Furthermore, all levels demonstrated differences among various regions. These findings suggest the need for more detailed BMD estimation, especially in patients undergoing spinal instrumentation in whom variations in local BMD can be used to guide surgical planning and could potentially impact clinical outcomes.

STUDY DESIGN:This was a retrospective cohort review.OBJECTIVE:The objective of this study was to determine the rate of fusion associated with an expandable cage and iliac crest bone graft in minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) surgery.SUMMARY OF BACKGROUND DATA:MI-TLIF is a commonly performed procedure, but challenges inherent in MI-TLIF technique can make achieving an interbody fusion difficult.METHODS:A retrospective review was performed on consecutive patients treated with an MI-TLIF for degenerative lumbar pathology. Patients that completed patient-reported outcome measures and 1-year computed tomography (CT)-scans for fusion analysis were included. Fusion morphology was analyzed by evaluating CT scans for location of bridging trabecular bone in relation to the cage. Patients with bridging bone were considered fused. Preoperative and postoperative health-related quality of life scores were compared. A Kolmogrov-Smirnoff test was used to determine normality of health-related outcome scores. A Friedman 2-way analysis of variance by ranks with pairwise comparisons to determine statistical significance of differences between the date of a follow-up examination and preoperative examination was done.RESULTS:Of 75 patients evaluated 23 patients were excluded due to loss to follow-up, adjacent segment degeneration, inability to obtain a CT scan, or reoperation for nonfusion related symptoms. Of 61 disk spaces that were included, 55 had bridging bone through the intervertebral cage, resulting in an overall fusion rate of 90.2%. There was a higher rate of fusion at L5-S1 as compared to L4-L5. There was mean improvement in patient-reported outcome measures for Oswestry Disability Index, Short Form-12 Physical Component Score, Visual Analog Scale Back/Leg pain, and Patient-Reported Outcome Measurement Information System Physical Function. There were no complications associated with iliac crest bone graft harvesting.CONCLUSION:Combining an expandable cage with iliac crest autograft bone harvested through a minimally invasive technique can allow for improved fusion rates without graft-site complications in MI-TLIF surgery.

Study Design: This was a prospective consecutive clinical cohort study. Objective: The purpose of our study was to develop and provide an initial internal validation of a novel classification system that can help surgeons and patients better understand their postoperative course following the particular minimally invasive surgery (MIS) and approach that is utilized. Summary of Background Data: Surgeons and patients are often attracted to the option of minimally invasive spine surgery because of the perceived improvement in recovery time and postsurgical pain. A classification system based on the impact of the surgery and surgical approach(es) on postoperative recovery can be particularly helpful. Methods: Six hundred thirty-one patients who underwent MIS lumbar/thoracolumbar surgery for degenerative conditions of the spine were included. Perioperative outcomes-operative time, estimated blood loss, postsurgical length of stay (LOS), 90-day complications, postoperative day zero narcotic requirement [in Morphine Milligram Equivalent (MME)], and need for intravenous patient-controlled analgesia (IV PCA). Results: Postoperative LOS and postoperative narcotic use were deemed most clinically relevant, thus selected as primary outcomes. Type of surgery was significantly associated with all outcomes (P< 0.0001), except intraoperative complications. Number of levels for fusion was significantly associated with operative time, in-hospital complications, 24 hours oral MME, and the need for IV PCA and LOS (P< 0.0001). Number of surgical approaches for lumbar fusion was significantly associated with operative time, 24 hours oralMME, need for IV PCA and LOS (P< 0.001). Based on these parameters, the following classification system ("Qureshi-Louie classification" for MIS degenerative lumbar surgery) was devised: (1) Decompressiononly; (2) Fusion-1 and 2 levels, 1 approach; (3) Fusion-1 level, 2 approaches; (4) Fusion-2 levels, 2 approaches; (5) Fusion-3+ levels, 2 approaches. Conclusions: We present a novel classification system and initial internal validation to describe the perioperative expectations following variousMIS surgeries in the degenerative lumbar spine. This initial description serves as the basis for ongoing external validation.

BACKGROUND CONTEXT Stand-alone or zero-profile devices for anterior cervical discectomy and fusion (zero-profile ACDF) have become popular in the management of degenerative cervical spine disease in order to mitigate some of the complications associated with anterior cervical plating. Studies regarding the incidence of postoperative complications after zero-profile ACDF are limited, particularly with regard to postoperative dysphonia. PURPOSE The aim of this study is to determine the incidence and overlap of voice and swallowing symptoms in patients undergoing zero-profile ACDF. STUDY DESIGN/SETTING Retrospective cohort study of prospectively collected data. PATIENT SAMPLE Patients who had undergone zero-profile ACDF between 2017-2020. OUTCOME MEASURES Patient-reported outcome measures (PROMs) - Patient reported responses on the Dysphagia, Odynophagia and Voice (DOV) Questionnaire. METHODS Patients completed the DOV Questionnaire preoperatively and at each postoperative timepoint (2 weeks, 6 weeks, 12 weeks, 6 months, 1 year and 2 years) as standard of care. The DOV Questionnaire requires patients to select one of five scaled answer choices (0-4) for dysphagia, and one of four scaled answer choices (0-3) for voice (ie, dysphonia) and odynophagia, with zero indicating no symptoms and higher point values indicating worse symptomatology. For this study, scores of 1, 2, 3, and 4 were graded as mild, moderate, severe, and very severe, respectively. The incidence of dysphonia, dysphagia and odynophagia were assessed. RESULTS Forty-eight patients, with a mean age of 58.46 ± 9.74 years, mean BMI of 27.38 ± 4.76 kg/m^2 and comprised of 31 males (64.6%) and 17 females (35.4%) were included. There were 17 single-level (35.4%), 24 two-level (50.0%) and 7 three-level (14.6%) surgeries. Twenty-four (50.0%) patients reported either new-onset dysphonia, dysphagia or odynophagia at their 2 or 6 week postoperative visit following zero-profile ACDF. Of these, 3 patients (6.25%) reported only dysphonia, 11 patients (22.9%) reported only dysphagia/odynophagia, and 10 patients (20.8%) reported both dysphonia and dysphagia/odynophagia. All cases of dysphagia and odynophagia were mild and a majority resolved within 12 weeks. Similarly, a majority (69%) of cases of dysphonia were mild and also resolved by 12 weeks. CONCLUSIONS Half of the patients in this cohort reported either dysphonia, dysphagia or odynophagia within 6 weeks of ACDF with the use of a zero-profile implant, most of which were mild and transient, resolving by 12 weeks. About half of all patients with swallowing symptoms reported concurrent voice symptoms, whereas the other half reported dysphagia/odynophagia alone. In contrast, approximately a quarter of all patients reported dysphonia within 6 weeks of zero-profile ACDF, most of whom also reported concurrent swallowing issues. However, 6.25% of patients reported dysphonia alone, which may not be detected using outcome measures that assess dysphagia only. Future research should evaluate these findings in a larger patient cohort and identify ways to reduce these complications. FDA DEVICE/DRUG STATUS Stand-alone ACDF cage (Approved for this indication). Stand-alone or zero-profile devices for anterior cervical discectomy and fusion (zero-profile ACDF) have become popular in the management of degenerative cervical spine disease in order to mitigate some of the complications associated with anterior cervical plating. Studies regarding the incidence of postoperative complications after zero-profile ACDF are limited, particularly with regard to postoperative dysphonia. The aim of this study is to determine the incidence and overlap of voice and swallowing symptoms in patients undergoing zero-profile ACDF. Retrospective cohort study of prospectively collected data. Patients who had undergone zero-profile ACDF between 2017-2020. Patient-reported outcome measures (PROMs) - Patient reported responses on the Dysphagia, Odynophagia and Voice (DOV) Questionnaire. Patients completed the DOV Questionnaire preoperatively and at each postoperative timepoint (2 weeks, 6 weeks, 12 weeks, 6 months, 1 year and 2 years) as standard of care. The DOV Questionnaire requires patients to select one of five scaled answer choices (0-4) for dysphagia, and one of four scaled answer choices (0-3) for voice (ie, dysphonia) and odynophagia, with zero indicating no symptoms and higher point values indicating worse symptomatology. For this study, scores of 1, 2, 3, and 4 were graded as mild, moderate, severe, and very severe, respectively. The incidence of dysphonia, dysphagia and odynophagia were assessed. Forty-eight patients, with a mean age of 58.46 ± 9.74 years, mean BMI of 27.38 ± 4.76 kg/m^2 and comprised of 31 males (64.6%) and 17 females (35.4%) were included. There were 17 single-level (35.4%), 24 two-level (50.0%) and 7 three-level (14.6%) surgeries. Twenty-four (50.0%) patients reported either new-onset dysphonia, dysphagia or odynophagia at their 2 or 6 week postoperative visit following zero-profile ACDF. Of these, 3 patients (6.25%) reported only dysphonia, 11 patients (22.9%) reported only dysphagia/odynophagia, and 10 patients (20.8%) reported both dysphonia and dysphagia/odynophagia. All cases of dysphagia and odynophagia were mild and a majority resolved within 12 weeks. Similarly, a majority (69%) of cases of dysphonia were mild and also resolved by 12 weeks. Half of the patients in this cohort reported either dysphonia, dysphagia or odynophagia within 6 weeks of ACDF with the use of a zero-profile implant, most of which were mild and transient, resolving by 12 weeks. About half of all patients with swallowing symptoms reported concurrent voice symptoms, whereas the other half reported dysphagia/odynophagia alone. In contrast, approximately a quarter of all patients reported dysphonia within 6 weeks of zero-profile ACDF, most of whom also reported concurrent swallowing issues. However, 6.25% of patients reported dysphonia alone, which may not be detected using outcome measures that assess dysphagia only. Future research should evaluate these findings in a larger patient cohort and identify ways to reduce these complications.

BACKGROUND CONTEXT Hounsfield units (HU), typically measured at L1-L2, have been identified as a surrogate marker for lumbar Bone Mineral Density (BMD). However, concern remains that L1-L2 BMD may not fully capture BMD differences throughout the lumbosacral spine and inadvertently provide inaccurate assessment. PURPOSE To evaluate the impact of how conventional HU evaluation relates to local HU at commonly instrumented levels, and to evaluate the impact of age and postmenopausal state on HU in the lumbar spine. STUDY DESIGN/SETTING Cross sectional comparative study. PATIENT SAMPLE Consecutive female patients presenting to a spine clinic between April 2017 and January 2019 who underwent lumbar CT were selected. Previous lumbar surgery, tumor, fracture or infection were excluded. OUTCOME MEASURES HU were assessed on lumbar CT by placing an elliptical region of interest confined to the medullary space of the vertebral body, and avoiding cortical bone or sclerosis. HU measurements were performed for L1-S1 in 7 regions of each vertebral body: mid-sagittal; axial-superior, waist, inferior; axial at the waist–anterior, middle, posterior. METHODS Patients were divided based on whether they were pre- or postmenopausal. HU were compared between the pre- and postmenopausal cohorts using student t-test or Mann-Whitney u-test. The difference between routinely used L1-L2 average HU and local HU in each region was calculated and compared between groups. Association of age and menopausal state with HU was assessed using regression analyses. RESULTS Forty-eight patients, 18 premenopausal and 30 postmenopausal were included. The postmenopausal group was significantly older (67 versus 41 years; p<0.0001). Postmenopausal women had lower HU in all regions at all levels (p<0.05), with the mean difference ranging from 45 to 90 HU. Depending on the region, the L1-L2 average was more than 10 units greater than L4 in 30–70% of premenopausal and 40–70% of postmenopausal women (p>0.05). L1-L2 average was also more than 10 units greater than L5 measurements in 17–78% of premenopausal and 40–70% of postmenopausal women (p>0.05, except sagittal region p=0.038). Age, but not BMI showed a significant negative correlation with HU, which was strong in premenopausal and moderate in postmenopausal women. Age and menopausal state account for 35-60% of the variability in HU, except in the posterior region, where they account for 25-45%. CONCLUSIONS Age and postmenopausal state were negatively associated with HU in the lumbosacral spine, and the conventionally used L1-L2 average did not adequately capture local HU variations. Local BMD assessment using HU may provide a more accurate assessment of morphometric characteristics and trabecular milieu in the operative region. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. Hounsfield units (HU), typically measured at L1-L2, have been identified as a surrogate marker for lumbar Bone Mineral Density (BMD). However, concern remains that L1-L2 BMD may not fully capture BMD differences throughout the lumbosacral spine and inadvertently provide inaccurate assessment. To evaluate the impact of how conventional HU evaluation relates to local HU at commonly instrumented levels, and to evaluate the impact of age and postmenopausal state on HU in the lumbar spine. Cross sectional comparative study. Consecutive female patients presenting to a spine clinic between April 2017 and January 2019 who underwent lumbar CT were selected. Previous lumbar surgery, tumor, fracture or infection were excluded. HU were assessed on lumbar CT by placing an elliptical region of interest confined to the medullary space of the vertebral body, and avoiding cortical bone or sclerosis. HU measurements were performed for L1-S1 in 7 regions of each vertebral body: mid-sagittal; axial-superior, waist, inferior; axial at the waist–anterior, middle, posterior. Patients were divided based on whether they were pre- or postmenopausal. HU were compared between the pre- and postmenopausal cohorts using student t-test or Mann-Whitney u-test. The difference between routinely used L1-L2 average HU and local HU in each region was calculated and compared between groups. Association of age and menopausal state with HU was assessed using regression analyses. Forty-eight patients, 18 premenopausal and 30 postmenopausal were included. The postmenopausal group was significantly older (67 versus 41 years; p<0.0001). Postmenopausal women had lower HU in all regions at all levels (p<0.05), with the mean difference ranging from 45 to 90 HU. Depending on the region, the L1-L2 average was more than 10 units greater than L4 in 30–70% of premenopausal and 40–70% of postmenopausal women (p>0.05). L1-L2 average was also more than 10 units greater than L5 measurements in 17–78% of premenopausal and 40–70% of postmenopausal women (p>0.05, except sagittal region p=0.038). Age, but not BMI showed a significant negative correlation with HU, which was strong in premenopausal and moderate in postmenopausal women. Age and menopausal state account for 35-60% of the variability in HU, except in the posterior region, where they account for 25-45%. Age and postmenopausal state were negatively associated with HU in the lumbosacral spine, and the conventionally used L1-L2 average did not adequately capture local HU variations. Local BMD assessment using HU may provide a more accurate assessment of morphometric characteristics and trabecular milieu in the operative region.

Study Design: Retrospective cohort study. Objective: The aim was to compare clinical outcomes in patients with significant cervical spondylosis treated with cervical disc replacement (CDR) compared with anterior cervical discectomy and fusion (ACDF). Summary of Background Data: As CDR utilization has increased over the past decade, recent studies have investigated the outcomes of CDR in patients with more significant spondylotic changes and demonstrated improved postoperative patient-reported outcomes (PROs). However, no prior study has investigated clinical outcomes of patients with significant spondylotic changes treated with CDR in comparison to ACDF. Methods: Patients who underwent 1-level or 2-level CDR or ACDF with significant cervical spondylosis, quantified using a validated grading scale, were identified, and prospectively collected data was retrospectively reviewed. The following PROs were analyzed: Neck Disability Index (NDI), visual analog scale-Neck, visual analog scale-Arm, and PROMIS Physical Function (PROMIS-PF) Computer Adaptive Test Score. Demographic, operative, and radiographic variables, and achievement of minimum clinically important difference (MCID) for each PRO were compared between the 2 groups. Results: A total of 66 patients were included in the present study, of which 35 (53%) were treated with CDR and 31 (47%) with ACDF. The preoperative cervical spondylotic grade was similar between the 2 groups (1.8 vs. 2.2, P=0.27). At final follow-up, there was no significant difference in the absolute value for each PRO between the 2 groups (P>0.19) and both groups demonstrated significant improvement in each PRO compared with preoperative values (P<0.01). There was no significant difference in the percentage of patients achieving the MCID for each PRO when comparing CDR to ACDF (P>0.09). Conclusions: A similar percentage of patients with significant degenerative cervical spondylosis achieved the MCID across multiple PROs when treated with CDR or ACDF. Patients in both treatment groups demonstrated significant improvement in all PROs assessed when compared with preoperative values. Level of Evidence: Level III.

BACKGROUND CONTEXT Stand-alone or zero-profile devices for anterior cervical discectomy and fusion (ACDF) have become popular in the management of degenerative cervical pathology in order to mitigate some of the complications associated with anterior cervical plating. PURPOSE To determine the incidence, severity and resolution of dysphagia and odynophagia following zero-profile ACDF. STUDY DESIGN/SETTING Retrospective cohort study of prospectively collected data. PATIENT SAMPLE Patients who had undergone zero-profile ACDF between 2017-2020. OUTCOME MEASURES Patient-reported Outcome Measure (PROMs) - Patient reported responses on the Dysphagia, Odynophagia and Voice (DOV) Questionnaire. In particular, the "Swallowing" and "Pain with Swallowing" components of the DOV Questionnaire were used for this study. METHODS Patients completed the DOV Questionnaire preoperatively and postoperatively (2 weeks, 6 weeks, 12 weeks, 6 months, 1 year and 2 years). Patients selected one of five answer choices (0-4) for dysphagia and one of four choices (0-3) for odynophagia, with zero indicating no symptoms and higher point values indicating worse symptomatology. Scores of 1, 2, 3, and 4 were graded as mild, moderate, severe, and very-severe, respectively. RESULTS Forty-eight patients, with a mean age of 58.46 ± 9.74 years, mean BMI of 27.38 ± 4.76 kg/m^2 and comprised of 31 males (64.6%) and 17 females (35.4%) were included. There were 17 single-level (35.4%), 24 two-level (50.0%) and 7 three-level (14.6%) surgeries. Nine (18.8%) patients reported dysphagia preoperatively, all of whom had symptom resolution. Ten (20.8%) patients reported dysphagia at 2 weeks postoperatively, which was mild in all patients. Of these, 5 had resolution during follow-up, with a majority reporting resolution by 6 weeks. Of the 5 patients that did not report resolution, 4 did not have follow-up data available beyond 6 weeks, and 1 reported persistent dysphagia at 2 years. Seven (16.7%) patients reported new-onset dysphagia at 6 weeks, which was mild in all patients. Of these, 5 had resolution, with a majority reporting resolution by 12 weeks. Of the 2 patients that did not report resolution, 1 patient did not have long-term follow-up available, and 1 reported persistent dysphagia at 1 year. Six (12.5%) patients reported odynophagia preoperatively, all of whom had complete symptom resolution. Eleven (22.9%) patients reported odynophagia at 2 weeks postoperatively, which was mild in all patients. Of these, 8 had resolution during the available follow-up, with a majority reporting resolution by 12 weeks. The 3 patients that did not report resolution did not have long-term follow-up data available. In addition, 5 (10.4%) patients reported new-onset, odynophagia after 2 weeks postoperatively, which was mild in all patients. Of these 5 patients, 4 reported resolution while 1 reported persistent symptoms at 1 year. Further, 6/48 (12.5%) patients reported only dysphagia, 4/48 (8.3%) patients reported only odynophagia, and 11/48 (22.9%) patients reported both dysphagia and odynophagia. CONCLUSIONS All cases of postoperative dysphagia and odynophagia were mild and a majority resolved by 6-12 weeks postoperatively. Only 2 (4.2%) patients reported persistent dysphagia and only 1 (2.1%) patient reported persistent odynophagia at or after 1 year postoperatively, which was mild in all cases. FDA DEVICE/DRUG STATUS Stand-alone ACDF cage (Approved for this indication). Stand-alone or zero-profile devices for anterior cervical discectomy and fusion (ACDF) have become popular in the management of degenerative cervical pathology in order to mitigate some of the complications associated with anterior cervical plating. To determine the incidence, severity and resolution of dysphagia and odynophagia following zero-profile ACDF. Retrospective cohort study of prospectively collected data. Patients who had undergone zero-profile ACDF between 2017-2020. Patient-reported Outcome Measure (PROMs) - Patient reported responses on the Dysphagia, Odynophagia and Voice (DOV) Questionnaire. In particular, the "Swallowing" and "Pain with Swallowing" components of the DOV Questionnaire were used for this study. Patients completed the DOV Questionnaire preoperatively and postoperatively (2 weeks, 6 weeks, 12 weeks, 6 months, 1 year and 2 years). Patients selected one of five answer choices (0-4) for dysphagia and one of four choices (0-3) for odynophagia, with zero indicating no symptoms and higher point values indicating worse symptomatology. Scores of 1, 2, 3, and 4 were graded as mild, moderate, severe, and very-severe, respectively. Forty-eight patients, with a mean age of 58.46 ± 9.74 years, mean BMI of 27.38 ± 4.76 kg/m^2 and comprised of 31 males (64.6%) and 17 females (35.4%) were included. There were 17 single-level (35.4%), 24 two-level (50.0%) and 7 three-level (14.6%) surgeries. Nine (18.8%) patients reported dysphagia preoperatively, all of whom had symptom resolution. Ten (20.8%) patients reported dysphagia at 2 weeks postoperatively, which was mild in all patients. Of these, 5 had resolution during follow-up, with a majority reporting resolution by 6 weeks. Of the 5 patients that did not report resolution, 4 did not have follow-up data available beyond 6 weeks, and 1 reported persistent dysphagia at 2 years. Seven (16.7%) patients reported new-onset dysphagia at 6 weeks, which was mild in all patients. Of these, 5 had resolution, with a majority reporting resolution by 12 weeks. Of the 2 patients that did not report resolution, 1 patient did not have long-term follow-up available, and 1 reported persistent dysphagia at 1 year. Six (12.5%) patients reported odynophagia preoperatively, all of whom had complete symptom resolution. Eleven (22.9%) patients reported odynophagia at 2 weeks postoperatively, which was mild in all patients. Of these, 8 had resolution during the available follow-up, with a majority reporting resolution by 12 weeks. The 3 patients that did not report resolution did not have long-term follow-up data available. In addition, 5 (10.4%) patients reported new-onset, odynophagia after 2 weeks postoperatively, which was mild in all patients. Of these 5 patients, 4 reported resolution while 1 reported persistent symptoms at 1 year. Further, 6/48 (12.5%) patients reported only dysphagia, 4/48 (8.3%) patients reported only odynophagia, and 11/48 (22.9%) patients reported both dysphagia and odynophagia. All cases of postoperative dysphagia and odynophagia were mild and a majority resolved by 6-12 weeks postoperatively. Only 2 (4.2%) patients reported persistent dysphagia and only 1 (2.1%) patient reported persistent odynophagia at or after 1 year postoperatively, which was mild in all cases.